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Year
after year we have seen cases of falls or syncope in which the potential role
of orthostatic hypotension has been inadequately assessed. Even when
orthostatic hypotension is considered as a potential contributory factor, we
often see that it is excluded because the correct assessment was never
performed. The proper technique for checking orthostatic signs is as follows:
First,
have the patient lie supine for at least 5 minutes prior to beginning
measurements. One should then measure both the blood pressure and pulse of the
patient in the supine position. Then, after telling the patient what you will
be doing and asking him to tell you about symptoms such as dizziness or graying
out of vision that might occur when upright, one stands the patient upright
(being sure you can safely lie him down if they do become symptomatic!). The
pulse should be measured first on standing since what the heart rate does in
response to orthostatic hypotension may provide clues to the etiology of the orthostatic
hypotension. The blood pressure is then recorded. If there is a drop in blood
pressure, one should keep the patient upright (unless symptomatic) and record
the blood pressure and pulse again at 1-2 minutes intervals until it has
stabilized.
Why
do all this? We ran an autonomic nervous system lab for many years and saw many
patients with symptomatic orthostatic hypotension. The reason for having the
patient lie supine for a significant period prior to first BP determination is
that patients with some neurological disorders, such as Multiple System
Atrophy, will have supine hypertension in addition to orthostatic hypotension.
The magnitude of their blood pressure drop will be much greater when going from
supine to standing rather than sitting to standing. The reason for checking the
pulse immediately on standing may provide clues to the etiology of any
orthostatic hypotension. If the autonomic nervous system is intact, you should
see a prompt increase in heart rate that plateaus and then stabilizes. That
pattern might be seen in patients whose orthostatic hypotension is caused by
dehydration, hypovolemia, some drugs, and other conditions. On the other hand,
the lack of such compensatory tachycardia might be seen in patients with
impaired autonomic nervous systems, such as those with diabetic polyneuropathy.
So,
why is this a patient safety issue? The best time to determine the primary
cause of a fall or factors contributing to a fall is immediately following a
fall or syncopal episode. We always recommend assessment for orthostatic
hypotension at the time of the event. But you may also proactively identify
orthostatic hypotension as a risk factor for falls and take steps to reduce
that risk.
A
recent study (Juraschek 2022) sheds light on the importance of proper
assessment for orthostatic hypotension. The Study to Understand Fall Reduction
and Vitamin D in You (STURDY) was a randomized trial of vitamin D3
supplementation and fall in community-based adults aged ≥70 years
at high risk of falls. Participants had blood pressure measurements going both
from sitting-to-standing and supine-to-standing.
Mean
BP increased 3.5 mmHg from sitting to standing but decreased with supine to
standing (mean change: −3.7 mmHg). Orthostatic hypotension (defined in
this study as a drop in systolic or diastolic BP of at least 20 or 10 mmHg)
was detected in 2.1% of seated versus 15.0% of supine assessments (P < 0.001).
While supine and seated OH were not associated with falls (HR1.55 vs 0.69),
supine systolic OH was associated with higher fall risk (HR 1.77). Supine OH
was associated with self-reported fainting, blacking out, seeing spots and room
spinning in the prior month, while sitting OH was not associated with any
symptoms They authors conclude that supine OH was more frequent, associated
with orthostatic symptoms, and potentially more predictive of falls than seated
OH.
Measuring the supine to standing BP and P thus is
important in the elderly population (or other population you might consider at
risk for falls). If you find significant orthostatic hypotension you may need
to take steps to reduce the magnitude of the BP drop or at least advise the patient about the risks of rapidly
going from supine to standing.
Some
of our prior columns stressing orthostatic hypotension and falls:
·
April
16, 2007 Falls with Injury
·
January
15, 2013 Falls on Inpatient Psychiatry
·
February
16, 2016 Fall Prevention Failing?
·
March
14, 2017 More on Falls on Inpatient Psychiatry
References:
Juraschek SP, Appel LJ, Mitchell CM, et al. Comparison of
supine and seated orthostatic hypotension assessments and their association
with falls and orthostatic symptoms. J Am Ger Soc 2022; 70(8): 2310-2319 First
Published: 22 April 2022
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17804
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